M. David Rudd, Ph.D., ABPP
Mr. Chairman and members of the Committee, thank you for the invitation and opportunity to join you here today and discuss the tragic, but important problem of suicide among our nation’s veterans. I am honored to be here. My scientific and clinical opinions are influenced by a diverse background as a practicing psychologist, clinical researcher whose work focuses on the assessment, management and treatment of suicidality, along with the fact that I’m a veteran. Having served previously as an Army psychologist, I’m keenly aware of the complexity and challenge of clinical decision making during wartime, the competing demands juggled by military mental health providers, and the arduous task of managing soldiers at risk for suicide both during active duty and after discharge. As a researcher, I understand suicide is most often the end outcome of a complex web of variables, several easily identified but not so easily treated. As a veteran, I have some understanding of what it means to serve our country, the personal and professional sacrifices that are made, and the potential consequences, but only a fraction compared to those that return from war struggling with injuries both visible and invisible.
The tragic increase in both active duty and veteran suicide rates since the beginning of Operation Iraqi Freedom and Operation Enduring Freedom (OIF/OEF) underscore a seldom recognized but very real fact about mental illness; that it can be fatal. Data are now available from multiple sources, including the Department of Veterans Affairs (VA), the recently released RAND Corporation study, along with the existing literature indicating that anywhere from a quarter to a third of previously deployed veterans present with a mental health problem following discharge. Most prominent among the problems are major depression, post-traumatic stress disorder (PTSD), traumatic brain injury (TBI), and substance abuse. Data available prior to the most recent military conflicts (OIF/OEF) indicated heightened suicide risk among the general veteran population, with estimates indicating that veterans are twice as likely to die by suicide, regardless of whether or not they were affiliated with the VA. More recent data indicate a marked increase in suicide risk among veterans being treated for depression, with the risk being 7-8 times greater than that for the general adult population in the United States. Similarly, recent revelations about suicide and suicide attempt rates among veterans have been alarming, with estimates as high as 18 suicides a day. Recent data on TBI are also of concern, indicating suicide rates in the range of 3-4 times the general population and lifetime suicide attempt rates of 8%, along with significant rates of suicidal ideation (23%). At this point, the relationship between brain injury and suicidality is not well understood.
An accurate and meaningful interpretation of these data requires a look at and consideration of comparable civilian data. Although it is certainly difficult to accurately estimate suicide rates for those in and out of treatment, there is some data for comparison. The suicide prevalence rate for major depression and affective disorders in general (i.e. major depression, bipolar disorder I and II and affective psychosis) is actually lower than often quoted. Rates differ depending on the apparent severity of the illness, with the outpatient suicide prevalence rate being 2%, in contrast to 6% for those previously hospitalized for suicidal symptoms and 4% for those hospitalized for other reasons. Rates of suicide attempts are much higher. It is estimated that as many 24% of those suffering major depression make a suicide attempt during the course of the illness. It is estimated that up to 50% of individuals with bipolar disorder will make a suicide attempt and up to 80% will manifest suicidal symptoms of some sort. Standardized mortality ratios (ratio of observed deaths to expected deaths) for major depression and bipolar disorder paint a stark picture; those with major depression evidence a twenty-fold increased risk for death by suicide relative to the general population and those with bipolar disorder a fifteen-fold increase in risk. There are data available regarding other disorders, but the take home message is that the risk for suicide is considerable for a number of mental illnesses. Mental illness can be fatal, particularly if unrecognized, untreated or under-treated.
It is also important to consider the expected rates of adverse events during treatment, in particular, suicide attempt rates. Data are available from randomized clinical trials targeting suicidal behavior (irrespective of diagnosis). Estimates indicate that as many as 40-47% of those receiving treatment (psychotherapy and medications) make suicide attempts during the first year of treatment. If an attempt is made during the first year, the average is approximately 2.5 attempts. This is what routinely happens during treatment. We also know that an individual making multiple suicide attempts will likely struggle with suicidality for many years, if not a lifetime. These data, coupled with data about recent discharge from the hospital, indicate that risk for suicide (in the context of mental illness) is not only potent but enduring. Standardized mortality ratios (ratio of observed deaths to expected deaths) for men and women recently discharged from the hospital range from 100 to 350 across several studies. These are tragically high numbers. The VA experience is not markedly different than its civilian counterpart when it comes to the presentation of high-risk suicidal patients.
There are several possible conclusions. First, as outlined nicely in the RAND study, there are high rates of psychiatric illness following combat exposure, including both direct and vicarious exposure. Multiple deployments for OIF/OEF likely compound the situation because of repeated combat exposure, sometimes after the initial emergence of symptoms. The VA is faced with assessing and treating large numbers of seriously ill veterans. Second, the overall rates of both suicide and suicide attempts are tragic but consistent with general trends for the types and observed rates of psychiatric illness. Third, an effective response requires effective resources. Finally, there is an element of this problem that is likely to be enduring and potentially chronic in nature.
The VA has already moved toward increasing recognition and treatment of suicidal veterans, implementing a telephone hotline and making available training on recognizing and responding to suicide warning signs. Treatment outcome studies targeting suicidality have confirmed that simple things work and can save lives. Limiting and removing access to the suspected method can save lives. Removing barriers to emergency care can save lives. Patient tracking and effective follow-up for treatment non-compliance can save lives. Evidence-based treatments for depression, bipolar disorder, PTSD are effective and can save lives. Despite the fact that treatment is effective, it’s estimated that only about half of those at risk pursue care.
The military and VA system face unique barriers to providing effective care, including issues of confidentiality, delays in evaluating the escalating numbers of service-connected disability claims, and misconceptions about the nature and effectiveness of mental health care. The FDA warning label for antidepressants is but one example of how misunderstanding of the scientific data can lead to fewer people expressing a willingness to seek care, with potentially tragic results. Science, clinical experience, and common sense converge when it comes to suicidality. Improving our ability to both recognize and respond quickly to those at risk can save lives. Removing barriers to care, particularly emergency care, can and will save lives. Those that have served our nation deserve no less. It is tragic and heartbreaking when a soldier that has survived the trauma of war returns home to die by his or her own hand, especially when treatment is an option.
Thank you, I appreciate the opportunity to speak with you today and welcome the chance to respond to questions.